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About McCall
Testimonials
How It Works
FAQs

JOIN THE WAIT LIST

Registration

Welcome to Modern Weight Loss. To be placed on the Wait List as a new patient, please complete the form below. We expect to open in early October 2024.

Please do not use this form if you are already a patient (you have seen any of our practitioners in the past). To set up patient portal access or amend your information, please contact us. If you are already a registered patient with online access, you can log in here.

Basic Information

Legal First Name *

Legal Last Name *

Date of birth *

Nickname (Preferred Name) *

Gender *

Male
Female
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Pronouns *

he/him/his
she/her/hers
they/them/theirs
Other
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Race *

American Indian or Alaska Native
White
Asian
Black or African American
Hawaiian or Other Pacific Islander
Hispanic or Latino
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Ethnicity *

Latino or Hispanic
not Latino or Hispanic
Other
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Treatment State *

Please choose the state in which you will be located at the time of your appointment:

Your Address

Address *

Address 2

City *

State *

Postal code *

Time Zone *

Pacific Time (PT) - Los Angeles (GMT-8)
Mountain Time (MT) - Denver (GMT-7)
Central Time (CT) - Chicago (GMT-6)
Eastern Time (ET) - New York (GMT-5)
Greenwich Mean Time (GMT) - London (GMT)
Central European Time (CET) - Berlin (GMT+1)
Eastern European Time (EET) - Athens (GMT+2)
Moscow Time (MSK) - Moscow (GMT+3)
Gulf Standard Time (GST) - Dubai (GMT+4)
Pakistan Standard Time (PKT) - Karachi (GMT+5)
India Standard Time (IST) - New Delhi (GMT+5:30)
Bangladesh Standard Time (BST) - Dhaka (GMT+6)
Indochina Time (ICT) - Bangkok (GMT+7)
China Standard Time (CST) - Beijing (GMT+8)
Japan Standard Time (JST) - Tokyo (GMT+9)
Australian Central Standard Time (ACST) - Adelaide (GMT+9:30)
Australian Eastern Standard Time (AEST) - Sydney (GMT+10)
New Zealand Standard Time (NZST) - Wellington (GMT+12)
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Contact Information

Mobile *

Home

Work

Preferred Contact *

Mobile Phone

Mobile Phone
Work Phone
Home Phone
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Email Address (Primary) *

Although it is not obligatory, we strongly advise registering with a Gmail address to optimize communication efficiency.

Secondary Email Address

Contact Preferences

Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails)

Email *

Yes (opt-in)

Yes (opt-in)
No (opt-out)
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SMS/Text *

Yes (opt-in)

Yes (opt-in)
No (opt-out)
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Emergency Contact

Emergency First Name *

Emergency Last Name *

Emergency Email *

Emergency Phone *

Vitals

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height *

Current Weight *

Blood Pressure Reading or enter "I don't know" *

Systolic
Diastolic
I don't know

Waist Circumference (in inches) *

Heart Rate *

Medical History

Check all that apply

High Blood Pressure

PreDiabetes

Hypertension

High Cholesterol

Type II Diabetes

Depression

Anxiety

Abnormal Cholesterol

PCOS or other fertility problems

Insulin Resistance

Metabolic Syndrome

Active Cancer under treatment

Liver Failure

Kidney Disease

Sever active heart disease

Heart Failure

Heart Disease

Hypothyroidism

Osteoarthritis

Sleep Apnea

Fatty Liver

Liver Inflammation

None

Other

Medical History Other

Which of the following conditions do you currently or have you previously have/had?

Alcohol Abuse

Gallbladder Disease

Stroke

Kidney Disease

End Stage Liver Disease

Pancreatitis, Current or Past

Gastroparesis, Current or Past

Seizure Disorder

None

Other

Conditions Other

Have you had any surgeries? *

Do you have a history of bariatric surgery? If so, what type and when? *

About You

Over the last 2 weeks, how many times have you had little or no interest - or pleasure in doing things? *

Not at all

+0 - Not at all
+1 - Several days
+2 - More than half the days
+3 - Nearly every day
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Over the last 2 weeks, how often have you felt down, depressed, or hopeless? *

Not at all

+0 - Not at all
+1 - Several days
+2 - More than half the days
+3 - Nearly every day
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Are you currently pregnant or breastfeeding? *

Yes

Yes
No
Breastfeeding
Not applicable
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Do you plan to become pregnant in the next 6 months? *

Yes

Yes
No
Don't Know
Not Applicable
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Is there any personal or family history of medullary thyroid cancer? *

Yes

Yes
No
Don't Know
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Is there any personal or family history of multiple endocrine neoplasia type 2 (MEN 2)? *

Yes

Yes
No
Don't Know
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Have you ever been diagnosed or treated for an eating disorder? *

Yes

Yes
No
Details Below
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Please share details about your eating disorder.

Weight Loss Journey

What have you tried in the past for weight loss? *

Dieting Plan

Dieting Plan
Exercise
Coaching
Weight Loss Medication
Other
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Which diets have you tried? *

Weight Watchers

Weight Watchers
Noom
Calibrate
found
Alpha
Push Health
Keto, Carnivore or Low Carb
Macro or calorie counting
Plant based
Other
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What other ways have you tried to lose weight?

How long has it been since you were at your ideal weight? *

What is your ideal weight (in pounds)? *

Medications and Allergies

Do you currently take medications? If so, please list them with dosages below.

Do you currently take supplements? If so, please list them below.

Are you allergic to any medications? If so, please list them; if no, write NKDA (No Known Drug Allergies)

Pharmacy Information

What is your preferred pharmacy? *

Pharmacy Address 1 *

Pharmacy Address 2

Pharmacy City *

Pharmacy State *

Pharmacy Zip *

Lab Preference

What is your Preferred Lab choice? *

Quest

LabCorp

Hear About Us *

Web Search

Doctor Referral

Friend / Word of Mouth

Thyroid Nation

Alive and Well

Podcast

Other

Referral Thanks

Consent *

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)."

"I have read and accept the terms of the privacy policy below:" *

Sign with mouse or finger *

Policies

Privacy Policy

Terms of Use

Telehealth Consent

Contact Us

[email protected]

3944 Ranch Rd 620 S

Building 6, Suite 100

Bee Cave, TX 78738

© 2024. Modern Weight Loss Clinic™. All rights reserved.

© 2024. Modern Weight Loss Clinic™. All rights reserved.